NORTHVILLE FAMILY PRACTICE

ETHNICITY QUESTIONNAIRE

Please fill in the following sections as completely and accurately as possible. This Questionnaire asks for information about your ethnic origin and language to help us provide health service to you. We are required to collect this information by the PCT (Primary Care Trust).

We aim to provide good Health Services for all people. In order to do this, we need to know more about the population we are serving and are therefore asking you to answer three questions on this form.

This will help us to provide the right type of healthcare services for all our patients. We need to know about language interpretation needs, for example, and about our populations’ religious and cultural requirements.

The personal information you give us on this form will have the same level of confidentiality as your medical records. This means it will not be shared with any other organisation, including other government departments such as The Home Office or The Inland Revenue. If you have any concerns about the use of the information please talk to a member of staff at the practice.

If you do not wish to complete this form please fill in the section at the end of the form.

Full Name:…………………………………….DOB:…………..Postcode……………

1. What do you consider to be your ethnic origin?

Asian or Asian BritishWhite

 Bangladeshi British

 Indian Irish

 Pakistani Gypsy

 Asian other (please State) Traveller

………………………………………… White other (please State)

………………………………………….

Black or Black BritishOther Ethnic Group

 African Chinese

 Caribbean Any Other (Please State)

 Black other (please State) …………………………………………..

…………………………………………

Mixed Background

 White and Asian

 White and Black African

 White and Black Caribbean

 Other mixed background (PleaseState)…………………………………………

P.T.O

2. How would you describe your religion?

 Christianity (all denominations)

 Islam

 Judaism

 Sikhism

 Hinduism

 Buddhism

 None

 Other (Please State)……………………………………………….

3. In the clinic, which language do you usually speak and read?

Speak / Read / Speak / Read
English /  /  / Mandarin /  / 
Albanian /  /  / Polish /  / 
Arabic /  /  / Punjabi /  / 
Bengali /  /  / Russian /  / 
Cantonese /  /  / Somali /  / 
Farsi /  /  / Turkish /  / 
French /  /  / Urdi /  / 
Gujarati /  /  / Other (please state) ……………………………….
Hindi /  / 

Thank you for helping us

I do not wish to complete this form

If you do not wish to complete this form, please can you state your reasons for not doing so (the information you provide will be maintained at a similar level of confidentiality to that of your medical record)

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